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General NPI Number Information
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NPI Number | 1659540870
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Entity Type | Organization
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Legal Business Name | GAUTAMI AGASTYA, MD., INC.
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Dates
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Enumeration Date | 02/21/2008
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Last Update Date | 02/13/2013
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Provider Practice Location Address
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Address Line | 652 W 11TH ST SUITE 137
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City | TRACY
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State | CA
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Zip | 95376-3869
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Country | US
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Telephone | 209-833-7555
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Fax | 209-833-7518
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Provider Business Mailing Address
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Address Line | 652 W 11TH ST SUITE 137
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City | TRACY
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State | CA
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Zip | 95376-3869
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Country | US
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Telephone | 209-833-7555
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Fax | 209-833-7518
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Authorized Official
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Title or Position | PRESIDENT
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Name | GAUTAMI AGASTYA
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Credential | MD
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Telephone | 209-833-7555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | C51385
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2083P0500X
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Taxonomy Name | Preventive Medicine/Occupational Environmental Medicine Physician
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License Number | A85126
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License Number State | CA
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